Request for Renewal of Wholesaler/NonResident Wholesaler Permit Complete the form below and submit to the Board of Pharmacy no more than 60 days before to the expiration date of the license. Enclose a check or money order in the amount of $600 if submitting before the expiration date, or $750 if the license has expired ($600 renewal fee plus $150 delinquency fee). Fees submitted more than 60 days before the expiration date will be returned. If there has been a change of ownership, location, corporate officer(s), shareholder (more than 10%), administrator, pharmacist-in-charge, or if you have negotiated a new lease with changes in terms and conditions you must immediately contact the Board of Pharmacy. Name of Wholesaler: License Number: Address: Expire Date: Telephone Number: The following certification must be signed by the owner, if an individual ownership; a partner, if a partnership; or a corporate officer, if a corporation. I certify, under penalty of perjury under the laws of the state of California, that there has been no change of ownership, location, corporate officers, or shareholders. Signature Print Name Date All items of information requested are mandatory. Failure to provide any of the information will result in the request for renewal being rejected as incomplete. The information will be used to determine qualifications for licensure under the California Pharmacy Law. The official responsible for information maintenance is the Executive Officer, telephone (916) 574-7900, 1625 N. Market Blvd, Suite N219, Sacramento, California 95834. The information may be transferred to another governmental agency such as a law enforcement agency if necessary for it to perform its duties. Each individual has the right to review the files or records maintained on them by our agency, unless the records are identified as confidential information and exempted by Section 1798.40 of the Civil Code. American LegalNet, Inc. www.FormsWorkflow.com